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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

Does your company issue guarantees, warranties or hold harmless agreements?:

Yes
No

Do you have a commercial auto policy?:

Yes
No

Does your company install, service or demonstrate any products?:

Yes
No

Does your company sell any foreign products?:

Yes
No

Does your company re-package or sell any products of others under your name?:

Yes
No

Do you draw plans, designs or specifications for other?:

Yes
No

Do you subcontract work to others?:

Yes
No

If yes (above), what percentage of your work is subbed out?:

%

Garage Coverage

If you are interested in Garage Coverage, please call us at the number below to discuss further:

Phone: 734-446-2722 or Toll Free: 1-888-606-4413

Automobile Coverage

Drivers Name:

Date of Birth:

Drivers License #:

State Licensed:

Drivers Name:

Date of Birth:

Drivers License #:

State Licensed:

Drivers Name:

Date of Birth:

Drivers License #:

State Licensed:

Year:

Make/Model:

VIN#:

Cost New:
$

City Garaged:

Year:

Make/Model:

VIN#:

Cost New:
$

City Garaged:

Year:

Make/Model:

VIN#:

Cost New:
$

City Garaged:

Year:

Make/Model:

VIN#:

Cost New:
$

City Garaged:

Year:

Make/Model:

VIN#:

Cost New:
$

City Garaged:

Are the vehicles above titled in any name other than the business name?:

Yes
No

Do you travel in a radius greater than 50 miles from your business?:

Yes
No

If yes, how far?:

Are Motor Vehicle Reports ordered for all drivers prior to hiring?:

Yes
No

Are any drivers not covered under a workers compensation policy?:

Yes
No

Workers' Compensation Coverage

Officer Name:

Title:

Ownership:

Include/Exclude*:
Include
Exclude

Salary (if included):
$

Officer Name:

Title:

Ownership:

Include/Exclude*:
Include
Exclude

Salary (if included):
$

Officer Name:

Title:

Ownership:

Include/Exclude*:
Include
Exclude

Salary (if included):
$

*Please note, if excluded, your health insurance may not cover all work related claims.

Please list each duty performed:
Clerical

Class code (if known):

# full time employees:

# part time employees:

Annual Payroll:
$

Please list each duty performed:
Sales

Class code (if known):

# full time employees:

# part time employees:

Annual Payroll:
$

Please list each duty performed:

Class code (if known):

# full time employees:

# part time employees:

Annual Payroll:
$

Please list each duty performed:

Class code (if known):

# full time employees:

# part time employees:

Annual Payroll:
$

Please list each duty performed:

Class code (if known):

# full time employees:

# part time employees:

Annual Payroll:
$

Please list each duty performed:

Class code (if known):

# full time employees:

# part time employees:

Annual Payroll:
$

Do you provide health insurance for 75% or more of your employees?:

Yes
No

Do you have a formal written safety program/manual in place?:

Yes
No

Federal Tax ID#:

Umbrella Coverage

Limit of Insurance:

$

Other Coverage

If you are interested in Other Coverage, please call us at the number below to discuss further:

Phone: 734-446-2722 or Toll Free: 1-888-606-4413

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.One of our representatives will respond to your submission as soon as possible.

Call us today!

Your insurance agent at Pietila Insurance Agency, Inc. can help you get the BEST coverage at the BEST rate for your business insurance!

Call (888)PIETILA for your consultation today!

9225 East M-36Whitmore Lake, MI 48189

(888)PIETILA (888-743-8452)

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